Healthcare Provider Details

I. General information

NPI: 1174683619
Provider Name (Legal Business Name): JILLIAN GRIZZARD FAJNA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W MAIN ST WAVERLY DRUGS
WAVERLY VA
23890
US

IV. Provider business mailing address

406 MEADOW BANK RD
EMPORIA VA
23847-7507
US

V. Phone/Fax

Practice location:
  • Phone: 804-834-2233
  • Fax:
Mailing address:
  • Phone: 434-634-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202011391
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: